Mini-CAT

Mini-CAT

Clinical Question: 

36 y/o male pt presents with multiple readings of high blood pressure (140/90s) on different occasions. Pt is not interested in being started on medications and is wondering if diet alone will provide as good of a benefit.

PICO Question:

In patients diagnosed with hypertension does the DASH diet when compared to anti-hypertensive medications lower blood pressure and better overall well being?

PICO Search Terms: 

P I C O
Hypertension DASH diet Anti-hypertensive medications Improved outcomes
High blood pressure Dietary Approaches to Stop Hypertension Standard care Lower blood pressure
Patients with Hypertension Alternative treatment Better overall well being

 

Google Scholar:

DASH diet for patients diagnosed with hypertension = 27,600 results

DASH diet for patients diagnosed with hypertension (Filters: 2020-2024, Sort by relevance, Review articles) = 4,410 results

– After applying the filters, I read the titles and abstracts of the articles from the first 5 pages and chose the ones that were most relevant.

Pub Med: 

DASH diet for patients diagnosed with hypertension = 251 results

DASH diet for patients diagnosed with hypertension (Filters: Within last 5 years) = 88 results

– After applying the filters, I read the titles of all 31 results and read the abstracts of the articles that were relevant and chose the articles for my PICO based on that.

Science Direct:

DASH diet for patients diagnosed with hypertension = 1,623 results

DASH diet for patients diagnosed with hypertension (Filters: 2020-2024, Review articles) = 187 results

– After applying the filters, I read the titles and abstracts for the first 4 pages and chose the ones that were most relevant to my search question. After the 4th page I noticed that the results weren’t relevant to my question.

Articles Chosen:

Article 1: Guo R;Li N;Yang R;Liao XY;Zhang Y;Zhu BF;Zhao Q;Chen L;Zhang YG;Lei Y; (2021) Effects of the modified dash diet on adults with elevated blood pressure or hypertension: A systematic review and meta-analysis, Frontiers in nutrition. Available at: https://pubmed.ncbi.nlm.nih.gov/34557511/

Abstract: 
Background: The modified Dietary Approaches to Stop Hypertension (DASH) diet was a potentially effective treatment for pre-hypertensive and hypertensive patients. The evidence for the effect of the modified DASH diet on blood pressure reduction was inconsistent. The study was designed to assess the effects of the modified DASH diet on blood pressure (BP) in hypertensive and pre-hypertensive adults. Methods: We searched Medline, Embase, CENTRAL, CNKI, VIP, Wanfang Data, SINOMED, Google Scholar, the World Health Organization’s International Clinical Trials Registry Platform, and Clinicaltrials.gov from inception to July 1st, 2021. Randomized controlled trials (RCTs) assessing the effects of the modified DASH diet on systolic and diastolic BP, cardiovascular risk factors (body weight, body mass index, waist circumference, fasting glucose, blood lipids), cardiovascular events, and all-cause mortality were included. Statistical analysis was performed using Stata software. Risk of bias was assessed with the Cochrane tool and quality of evidence with GRADE. Results: A total of 10 RCTs were included. Compared with control diet, the modified DASH diet could reduce mean systolic (-3.26 mmHg; 95% confidence interval -5.58, -0.94 mmHg; P = 0.006) and diastolic (-2.07 mmHg; 95% confidence interval -3.68, -0.46 mmHg; P = 0.01) BP. Compared with the controlling diet, the modified DASH diet could reduce systolic BP to a greater extent in trials with a mean baseline BP ≥ 140/90 mmHg compared with <140/90 mmHg. Diastolic BP reduction was greater when the mean body mass index was ≥30 kg/m2 than <30 kg/m2. Diastolic BP reduction was more marked in trials with a follow-up time of >8 weeks compared with ≤8 weeks. The modified DASH diet could affect mean waist circumference (difference: 1.57 cm; 95% confidence interval -2.98, -0.15) and triglyceride concentration (difference: 1.04 mol/L; 95% confidence interval -1.47, -0.60). Conclusions: The modified DASH diet can reduce BP, waist circumference, and triglyceride concentration in hypertension patients. A higher baseline BP is associated with more marked systolic and diastolic BP reduction.
Article 2: Theodoridis, X. et al. (2023) Adherence to the dash diet and risk of hypertension: A systematic review and meta-analysis, Nutrients. Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10383418/

Abstract:
The aim of this study was to assess the effect of the level of adherence to the DASH diet on hypertension risk by conducting a systematic review and meta-analysis. A systematic literature search was performed. Two independent investigators performed the study selection, data abstraction, and assessment of the included studies. The meta-analysis was performed separately with the adjusted hazard (HR) or incident rate ratios (IRR) and the odds ratios (OR) of the highest compared to the lowest DASH diet adherence scores using a random effects model. A total of 12 studies were included in the qualitative and quantitative synthesis. When cohort studies reporting HR were pooled together, high adherence to the DASH diet was associated with a lower risk of hypertension (HR: 0.81, 95% CI 0.73–0.90, I2 = 69%, PI 0.61–1.08) compared to the low adherence. When cross-sectional studies reporting OR were combined, high adherence to the DASH diet was also related to a lower risk of hypertension (OR: 0.80, 95% CI 0.70–0.91, I2 = 81%, PI 0.46–1.39). The findings suggest that high adherence to the DASH diet has a positive effect on reducing hypertension risk compared to low adherence. These data strengthen and are in line with all hypertension guidelines, indicating that lifestyle changes should start early even in populations with normal blood pressure.
Article 3:  Filippou, C.D. et al. (2020) Dietary approaches to stop hypertension (DASH) diet and blood pressure reduction in adults with and without hypertension: A systematic review and meta-analysis of randomized controlled trials, Advances in nutrition (Bethesda, Md.). Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7490167/

Abstract:
The Dietary Approaches to Stop Hypertension (DASH) diet is recognized as an effective dietary intervention to reduce blood pressure (BP). However, among randomized controlled trials (RCTs) investigating the DASH diet–mediated BP reduction, there are significant methodological and clinical differences. The purpose of this study was to comprehensively assess the DASH diet effect on BP in adults with and without hypertension, accounting for underlying methodological and clinical confounders. We systematically searched Medline and the Cochrane Collaboration Library databases and identified 30 RCTs (n = 5545 participants) that investigated the BP effects of the DASH diet compared with a control diet in hypertensive and nonhypertensive adults. Both random-effects and fixed-effect models were used to calculate the mean attained systolic BP (SBP) and diastolic BP (DBP) differences during follow-up. Subgroup and meta-regression analyses were also conducted. Compared with a control diet, the DASH diet reduced both SBP and DBP (difference in means: −3.2 mm Hg; 95% CI: −4.2, −2.3 mm Hg; P < 0.001, and −2.5 mm Hg; 95% CI: −3.5, −1.5 mm Hg; P < 0.001, respectively). Hypertension status did not modify the effect on BP reduction. The DASH diet compared with a control diet reduced SBP levels to a higher extent in trials with sodium intake >2400 mg/d than in trials with sodium intake ≤2400 mg/d, whereas both SBP and DBP were reduced more in trials with mean age <50 y than in trials of older participants. The quality of evidence was rated as moderate for both outcomes according to the Grading of Recommendations, Assessment, Development, and Evaluation approach. The adoption of the DASH diet was accompanied by significant BP reduction in adults with and without hypertension, although higher daily sodium intake and younger age enhanced the BP-lowering effect of the intervention.
Article 4: LP;, M.T.P.J.  Dash (dietary approaches to stop hypertension) diet is effective treatment for stage 1 isolated systolic hypertension, Hypertension (Dallas, Tex. : 1979). Available at: https://pubmed.ncbi.nlm.nih.gov/11509468/ (Accessed: 30 June 2024).

Abstract:

Use of the DASH (Dietary Approaches to Stop Hypertension) diet, which is rich in fruits, vegetables, and low-fat dairy foods, significantly lowers blood pressure. Among the 459 participants in the DASH Trial, 72 had stage 1 isolated systolic hypertension (ISH) (systolic blood pressure, 140 to 159 mm Hg; diastolic blood pressure, <90 mm Hg). We examined the blood pressure response in these 72 participants to determine whether the DASH diet is an effective treatment for stage 1 ISH. After a 3-week run-in period on a typical American (control) diet, participants were randomly assigned for 8 weeks to 1 of 3 diets: a continuation of the control diet (n=25), a diet rich in fruits and vegetables (n=24), or the DASH diet (n=23). Sodium content was the same in the 3 diets, and caloric intake was adjusted during the trial to prevent weight change. Blood pressure was measured at baseline and at the end of the 8-week intervention period with standard sphygmomanometry. Use of the DASH diet significantly lowered systolic blood pressure compared with the control diet (-11.2 mm Hg; 95% confidence interval, -6.1 to -16.2 mm Hg; P<0.001) and the fruits/vegetables diet (-8.0 mm Hg; 95% confidence interval, -2.5 to -13.4 mm Hg; P<0.01). Overall, blood pressure in the DASH group fell from 146/85 to 134/82 mm Hg. Similar results were observed with 24-hour ambulatory blood pressure measurements. In the DASH diet group, 18 of 23 participants (78%) reduced their systolic blood pressure to <140 mm Hg, compared with 24% and 50% in the control and fruits/vegetables groups, respectively. Our results indicate that the DASH diet, which is rich in fruits, vegetables, and low-fat dairy foods, is effective as first-line therapy in stage 1 ISH.

Article 5: Kenmoue, M.F.D. et al. (2023) Assessing the effectiveness of a DASH diet in hypertensive patients attending the Ngaoundere Regional Hospital – Cameroon: A case-control study, Journal of nutritional science. Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10388434/

Abstract: 

Hypertension remains a public health issue in Cameroon, though lifestyle and dietetic measures are the main approaches for the prevention and management of hypertension. The present study aimed at evaluating the impact of a Dietary Approaches to Stop Hypertension (DASH) diet using local foodstuffs on the status of hypertensive patients at the Ngaoundere Regional Hospital. A case–control study was carried out with 160 hypertensive patients divided into two groups, a test and a control group. A food questionnaire was used to evaluate the food habits of patients and design the sheet of the DASH diet to provide a maximum of 2000 kcal/d. The DASH diet was administered to the test group (eighty-eight patients), while the control group (seventy-two patients) consumed their normal diet. Both groups were followed up for 8 weeks. The systolic and diastolic blood pressures (SBP, DBP), body mass index (BMI), triglycerides, HDL–c, LDL-c and total-cholesterol levels of patients of the two groups were measured before and after the intervention. The results indicate that the DASH diet improves all the markers of hypertension in the test group with significant decreases in BMI, SBP, DBP, LDL-c and total-cholesterol. Patients of the control group had fourteen and seven times more risk of having increased systolic and diastolic pressures, respectively, and are thus exposed to hypertension complications. The DASH diet established in this study is therefore effective for the management of hypertension.
Summary of the Evidence:
Guo, Ru; & Yang, Rang etc 2021 Systemic Review & Meta-anaylsis Medline, Embase, CENTRAL, CNKI, VIP, Wanfang Data, SINOMED, Google Scholar, the World Health Organization’s International Clinical Trials Registry Platform, and Clinicaltrials.gov

Meta-analysis included A total of 10 RCTs were included.

 To assess the effects of the modified DASH diet on blood pressure (BP) in hypertensive and pre-hypertensive adults. Compared with control diet, the modified DASH diet could reduce mean systolic (-3.26 mmHg; 95% confidence interval -5.58, -0.94 mmHg; P = 0.006) and diastolic (-2.07 mmHg; 95% confidence interval -3.68, -0.46 mmHg; P = 0.01) BP.

Compared with the controlling diet, the modified DASH diet could reduce systolic BP to a greater extent in trials with a mean baseline BP ≥ 140/90 mmHg compared with <140/90 mmHg. Diastolic BP reduction was greater when the mean body mass index was ≥30 kg/m2 than <30 kg/m2.

 Control and dash diet may have different nutrient contents which may affect results.
Theodoridis, Xenophon;Chroni, Violeta; etc 2023 Systemic Review & Meta-anaylsis Two independent investigators performed the study selection, data abstraction, and assessment of the included studies.

A total of 12 studies were included in the qualitative and quantitative synthesis.

 To assess the effect of the level of adherence to the DASH diet on hypertension risk. When cohort studies reporting HR were pooled together, high adherence to the DASH diet was associated with a lower risk of hypertension (HR: 0.81, 95% CI 0.73–0.90, I2 = 69%, PI 0.61–1.08) compared to the low adherence.

When cross-sectional studies reporting OR were combined, high adherence to the DASH diet was also related to a lower risk of hypertension (OR: 0.80, 95% CI 0.70–0.91, I2 = 81%, PI 0.46–1.39).

 For the cross-sectional studies, the articles did not provide enough information about the study subjects and the setting.
Filippou, Christina; Tsioufis Costas; etc 2020 Systemic Review & Meta-anaylsis  Systematically searched Medline and the Cochrane Collaboration Library databases and identified 30 RCTs (n = 5545 participants) To comprehensively assess the DASH diet effect on BP in adults with and without hypertension, accounting for underlying methodological and clinical confounders. Compared with a control diet, the DASH diet reduced both SBP and DBP (difference in means: −3.2 mm Hg; 95% CI: −4.2, −2.3 mm Hg; P < 0.001, and −2.5 mm Hg; 95% CI: −3.5, −1.5 mm Hg; P < 0.001, respectively). Hypertension status did not modify the effect on BP reduction.

The DASH diet compared with a control diet reduced SBP levels to a higher extent in trials with sodium intake >2400 mg/d than in trials with sodium intake ≤2400 mg/d, whereas both SBP and DBP were reduced more in trials with mean age <50 y than in trials of older participants.

 Both the recommended DASH and control diets in each trial were not identical in terms of macro- and micronutrient content.
Moore, TJ; Conlin, PR; etc 2001 Systemic Review Cochrane Pregnancy and Childbirth’s Trials Register, and the WHO International Clinical Trials Registry Platform

Twelve trials (1,856 women) met the inclusion criteria. Eight of the included trials compared treatment with placebo and the remaining four trials compared progestogen administration with no treatment.

 To determine whether the DASH diet is an effective treatment for stage 1 ISH. Use of the DASH diet significantly lowered systolic blood pressure compared with the control diet (-11.2 mm Hg; 95% confidence interval, -6.1 to -16.2 mm Hg; P<0.001) and the fruits/vegetables diet (-8.0 mm Hg; 95% confidence interval, -2.5 to -13.4 mm Hg; P<0.01). Adherence to the strict fruits/vegetables diet is unknown and can cause biased results.
Kenmoue, Mireille; Ngaha, Wilfred etc 2023 Case – Control Study The present study aimed at evaluating the impact of a Dietary Approaches to Stop Hypertension (DASH) diet using local foodstuffs on the status of hypertensive patients at the Ngaoundere Regional Hospital.

A case–control study was carried out with 160 hypertensive patients divided into two groups, a test and a control group.

 To evaluate the impact of a Dietary Approaches to Stop Hypertension (DASH) diet using local foodstuffs on the status of hypertensive patients The results indicate that the DASH diet improves all the markers of hypertension in the test group with significant decreases in BMI, SBP, DBP, LDL-c and total-cholesterol.

Patients of the control group had fourteen and seven times more risk of having increased systolic and diastolic pressures, respectively, and are thus exposed to hypertension complications.

 The selection of patients (88 for DASH diet) and (72 with normal diet) could have some bias in selection.

Conclusions: 

Article 1: 

– Overall, the evidence of this article suggests that the modified DASH diet can reduce BP, waist circumference, and triglyceride concentration in hypertension patients.

– A higher baseline BP is associated with more marked systolic and diastolic BP reduction.

Article 2: 

– The results of this article suggest that high adherence to the DASH diet has a positive effect on reducing hypertension risk compared to low adherence.

– These data strengthen and are in line with all hypertension guidelines, indicating that lifestyle changes should start early even in populations with normal blood pressure.

Article 3:

– The adoption of the DASH diet was accompanied by significant BP reduction in adults with and without hypertension, although higher daily sodium intake and younger age enhanced the BP-lowering effect of the intervention.

Article 4: 

–  The results indicate that the DASH diet, which is rich in fruits, vegetables, and low-fat dairy foods, is effective as first-line therapy in stage 1 ISH.

Article 5: 

– The results indicate that the DASH diet improves all the markers of hypertension in the test group with significant decreases in BMI, SBP, DBP, LDL-c and total-cholesterol.

– Patients of the control group had fourteen and seven times more risk of having increased systolic and diastolic pressures, respectively, and are thus exposed to hypertension complications.

Overarching Conclusion:

– In conclusion, patients that are diagnosed with hypertension, the DASH diet has shown to significantly reduce not only blood pressure but also waist circumference and triglyceride concentration. All of the articles state that adhering to the DASH diet provided promising results in terms of lowering blood pressure and overall better well-being of patients.

Clinical Bottom Line:

Weight of Evidence: 

Article 2: This article had the best evidence and data when compared to the rest of the articles as it is a Systemic review and Meta-analysis article. The data included 10 Randomized Control Trials. Compared to the rest of the articles, this article contains the least amount of limitations/bias which means it has the most reliable data compared to the rest.

Article 1: I would rank this article as second on my weight of evidence as it is also a Systemic Review and Meta-Analysis article. This article also has top level evidence and includes 12 studies discusses studies of 12 trials included in the qualitative and quantitative synthesis. This article does contain some biases/limitations which may affect the results which is why I ranked it under article 2.

Article 3: I would rank this article as third on my weight of evidence as it also a Systemic Review and Meta-anaylsis article like Articles 1 and 2 but contains more bias/limitations. This article is beneficial because it contains 30 RCTs. The bias/limitations is the main reason I have this at number 3.

Article 4: I am ranking this as 4th on my weight of evidence because although this is a Systemic Review article that includes Twelve trials (1,856 women) met the inclusion criteria, there is risk of increased bias and my first 3 articles are also Meta-Analysis.

Article 5: I am ranking this as my last article because this is a Case-Control study article meaning compared to my other articles which are Systemic review and Meta-Analysis, this does not have the best evidence. There also aren’t as many trials that are done compared to the other articles meaning that the risk of bias is increased.

Magnitude of any effects: 

– All of the articles emphasized the importance of adherence of the DASH diet and I believe there needs to be further research on how long patients must adhere and the effects of not following the DASH diet for some period of time.

Clinical Significance:

– Overall, based on all of the evidence provided in the articles it is clear that DASH diet is definitely effective in lowering blood pressure and providing great benefits in the overall well-being of patients. I would recommend the DASH diet to all patients regardless of their blood pressure and if patients require blood pressure medications because their blood pressure is too high, then I would recommend the DASH diet as an adjunct. There needs to be further research done on the stages of hypertension and how the DASH diet can play a role as an adjunct.